Provider Demographics
NPI:1043841620
Name:KEIGI, MARK NDUGO (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:NDUGO
Last Name:KEIGI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 SQUIRREL DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-2765
Mailing Address - Country:US
Mailing Address - Phone:786-328-9209
Mailing Address - Fax:
Practice Address - Street 1:2821 SQUIRREL DR
Practice Address - Street 2:
Practice Address - City:BEAR
Practice Address - State:DE
Practice Address - Zip Code:19701-2765
Practice Address - Country:US
Practice Address - Phone:786-328-9209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019034785208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2019304785OtherASSISTANT PHYSICIAN LICENSE